Volume 89, Issue 1 , Pages 153-156, January 2008
Ultrasound-Guided Intra-Articular Injection of the Trapeziometacarpal Joint: Description of Technique
Article Outline
Abstract
Umphrey GL, Brault JS, Hurdle M-FB, Smith J. Ultrasound-guided intra-articular injection of the trapeziometacarpal joint: description of technique.
Objective
To describe a new technique to perform an ultrasound-guided intra-articular injection of the trapeziometacarpal (TMC) joint.
Design
Ultrasound-guided injection of the TMC joint was completed on fresh frozen cadaver hand specimens using diatriazoate meglumine contrast. A fluoroscopic posteroanterior image of the TMC joint was then obtained to verify intra-articular placement of the contrast.
Setting
Anatomy lab in a medical college.
Specimens
Seventeen fresh frozen cadaver hand specimens.
Interventions
Not applicable.
Main Outcomes Measure
Verification of this technique was confirmed using fluoroscopy and contrast.
Results
Sixteen (94%) of 17 joints injected showed contrast material within the TMC joint with a single cutaneous puncture. One intra-articular injection was initially misplaced into the scaphotrapeziotrapezoid joint.
Conclusions
Ultrasound may be used to accurately perform intra-articular TMC injections. Ultrasound provides a viable alternative to fluoroscopy when accurate injection into the TMC joint is required for diagnostic or therapeutic purposes.
Key Words: Arthritis, Carpometacarpal joints, Injections, Rehabilitation, Ultrasonography, Wrist
THE TRAPEZIOMETACARPAL (TMC) joint is among the most common sites of arthritis in the wrist and hand.1, 2, 3 Patients with symptomatic arthritis in this region may have significant pain and disability precipitating a medical evaluation. First line treatments include analgesics, anti-inflammatories, hand therapy, splinting, and activity modification.4 When these measures fail, intra-articular corticosteroid injections have been used to alleviate pain and inflammation.5 In other cases, anesthetic injections may be used to determine whether the TMC joint is a significant pain generator. In either situation, accurate needle placement is necessary for diagnostic or therapeutic injections. Although 1 investigation has reported a 58% success rate of nonguided needle placement into the TMC joints in 60 patients, another study reported 100% accuracy in a group of 32 patients.1, 6 In a recent study investigating the accuracy of intra-articular injection of the basal joint, the accuracy rate of the nonguided injection group was 81.8%, whereas the rate for the fluoroscopic-guidance group was 100%.7
Although some experienced clinicians may be able to access the TMC joint nearly 100% of the time, alternative approaches to ensure accurate needle placement may be reasonable for less experienced operators, or in cases of arthritic deformity and failed nonguided steroid injection. Fluoroscopy has traditionally been advocated to facilitate intra-articular needle placement under direct visualization, and confirmation of correct placement with contrast injection.1, 8 However, fluoroscopy is an expensive and bulky unit to purchase, exposes the operator and patient to harmful ionizing radiation, and fails to define soft tissue and neurovascular structures.8 Furthermore, contrast material injected in a small joint for fluoroscopic visualization inherently reduces the volume of injected medication, which could decrease the desired therapeutic effect. In comparison, ultrasound provides an alternative means of ensuring accurate needle placement and has several noteworthy advantages because it has no contraindications, produces no radiation exposure to the patient or operator, does not require contrast, and is well tolerated by patients.8, 9
The purposes of this study was to describe a technique to perform an ultrasound-guided intra-articular steroid injection of the TMC joint and to verify its accuracy using contrast fluoroscopy as our criterion standard using fresh frozen human cadaver hand specimens. We hypothesized that, with the proposed technique, ultrasound will provide 100% accuracy in intra-articular needle placement into the TMC joint with a single attempt. The results of this investigation may provide an alternative to fluoroscopy when accurate injection into the TMC joint is required for diagnostic or therapeutic purposes.
Methods
Technique
Two of the 4 authors regularly perform ultrasound-guided shoulder, hip, small joint, and soft tissue injections in their practices. One author regularly performs nonguided TMC joint injections in his hand practice, and uses ultrasound-guided TMC joint injection in patients who have failed a prior nonguided injection, or in patients with severely distorted basilar joint anatomy due to arthritis. The ultrasound-guided injections were performed by a senior resident physician and 3 senior staff physicians in physical medicine and rehabilitation at a tertiary care center, all of whom have more than 3 years of experience in performing ultrasound-guided injections of large and small joints. Five injections were performed by the resident physician, and each of the 3 staff physicians performed 4 injections. Ultrasound-guided injections were performed using a Toshiba Nemio 20 ultrasound machinea and a Toshiba Nemio PLM-1202S, 8- to 14-MHz linear array “hockey stick” transducer.a A successful injection was determined by the presence of contrast agent within the TMC joint on fluoroscopic imaging.
Seventeen fresh frozen cadaver upper limbs (10 right hands, 7 left hands) were randomly provided by the institutions’ anatomy lab, without any prior history of age, sex, hand dominance, or degree of basilar thumb carpometacarpal arthritis. Review board approval was not necessary. After the limbs were thawed, each limb was placed palm up, with the digits directed toward the clinician to simulate a clinical setting. The volar-radial aspect of the thumb metacarpal was palpated from distal to proximal, and the transducer was oriented parallel to the thumb metacarpal along its volar-radial aspect. Maintaining this orientation, the transducer was then slowly advanced proximally until a hypoechoic cleft defining the base of the thumb metacarpal, and the distal aspect of the trapezium was identified. This cleft defined the TMC joint (fig 1). The transducer orientation and machine settings were then adjusted to optimize the view of the joint, with the hypoechoic joint cleft centered under the transducer. At this point, either a 25-gauge (12 hands) or 27-gauge (5 hands) 38-mm needle with syringe containing 1mL of anechoic diatriazoate meglumineb contrast agent was centered directly perpendicular to the transducer. Increased echogenicity, and thus better needle visualization, was achieved using a 25-gauge needle compared with the initially used 27-gauge needle. Anechoic diatriazoate meglumine contrast was used because it has similar flow patterns to corticosteroid and is relatively inexpensive. The needle was then angled 30° to 45° relative to the transducer (fig 2), and advanced under direct ultrasound visualization into the hypoechoic cleft defining the TMC joint until a soft “pop” was felt. This “pop” represented capsular penetration and was accompanied by a subtle loss of resistance representing needle penetration into the joint. After visualization of the needle tip within the joint (fig 3) 0.5mL of contrast was instilled. As the injectate filled the joint space, the hyperechoic capsule was observed distending, confirming intra-articular placement. After completion of the contrast injection, a fluoroscopic posteroanterior image of the TMC joint was then obtained to verify intra-articular placement of the contrast (fig 4).
Fig 1.
Preinjection ultrasound of the TMC joint in a cadaver specimen.
Fig 2.
Ultrasound transducer over TMC joint in a cadaver specimen. Needle is positioned on the volar side of the transducer at the midpoint of the transducer’s long axis. Path of entry is 30° to 45° relative to the transducer.
Fig 3.
Postinjection image showing ultrasound-guided injection of the TMC joint in a cadaver specimen. A hypoechoic cleft is visualized between the trapezium (left) and first metacarpal (right) defining the joint space. The needle tip is visualized in the center of the joint space.
Fig 4.
Left posteroanterior view of the wrist in a cadaver specimen. Fluoroscopic imaging of the first carpometacarpal joint confirming contrast material in joint space and expansion of the surrounding joint capsule.
Results
Although not specifically assessed, a wide range of osteoarthritic changes were observed in the TMC joints of the specimens, including severe osteophytic change in 1 joint that required a slight modification of the approach. This modification involved moving the transducer in a more dorsal-radial position over the thumb metacarpal, and advancing the transducer proximally until the hypoechoic cleft was encountered. Overall, 16 (94%) of 17 joints injected showed contrast material within the TMC joint after a single cutaneous puncture. One of the 17 joints injected showed contrast material to be contained with the scaphotrapeziotrapezoid joint. After needle withdrawal and transducer repositioning, the needle and injectate was successfully placed on the second pass. The elapsed time was 3 to 5 minutes from placement of the ultrasound gel and probe to localizing the TMC joint space and injection of solution, depending on the degree of arthritic change at the basilar joint. This is comparable with a standard TMC joint injection in our clinics. This technique was not performed under sterile conditions, and therefore did not require a second assistant. When performed in clinical practice, maintaining a sterile field may add to the total injection time. This, however, was not studied.
Discussion
We have described a straightforward technique for using ultrasound to place needles into the trapeziometacarpal articulation, and verified its accuracy in a cadaver model. Using contrast controlled fluoroscopy as our criterion standard, 94% of our injections were placed within the TMC joint. We used a total volume of 0.5mL for intra-articular injection. Anecdotally, standard TMC joint injection total volume ranges from 0.5mL to 1mL in clinical practice. It is notable that several TMC joints that we injected were very arthritic and exhibited incompetent joint capsules, which was evident from a small amount of contrast extravasation. The technique described herein is relatively simple to perform, and the most difficult injections may be completed in less than 5 minutes. This time is comparable with a standard nonguided TMC joint injection in our clinics. Although this study was performed without the assistance of a second person, an assistant may be needed to help set up a sterile field when performed in clinical practice.
Although we studied this technique in cadavers, we use this injection in our patients on a regular basis when clinically indicated. We find ultrasound guidance particularly useful in patients with severely arthritic TMC joints, and in patients who have failed a nonguided injection. We also find it useful when precision is necessary for diagnostic purposes. The basic approach we describe herein and use clinically is a short axis approach, in which the needle is perpendicular to the long axis of the transducer. Because the needle appears as a “dot” using this approach, needle visualization can be challenging for the inexperienced operator or in patients with severely distorted joint margins.
Based on cadaveric analysis, we hypothesized that ultrasound would provide 100% accuracy in intra-articular needle placement into the TMC joint with a single attempt. Our results showed a deviation from our hypothesis with inability to accurately place contrast agent within the TMC joint on first attempt, on 1 specimen. This injection was performed by an author who deviated from the abovementioned technique. This author had the ultrasound machine set to a narrow field of view, and also did not identify the landmarks described above. The joint identified appeared similar to the TMC joint, and thus contrast agent was injected into this joint, which was the scaphotrapeziotrapezoid joint. The ultrasound field of view was readjusted and the needle was subsequently repositioned under ultrasound guidance. Using the aforementioned technique, the contrast agent was appropriately delivered to the TMC joint, as confirmed with fluoroscopy. The author who missed the TMC joint has greater experience than the other authors in nonguided TMC joint injections, but less experience with ultrasound usage. The technique is therefore, not infallible, and the steps of appropriate identification and optimizing the ultrasounds’ field of view prior to injection should be performed.
One prior observational study reporting a TMC joint injection success rate of 58% included house officers and a senior consultant, who performed the injections in 60 TMC joints over a 12-month period. In this investigation, the operator inserted the needle without image guidance into the position clinically assessed to be the TMC joint, and the position was assessed using fluoroscopy. The needle was incorrectly placed in 42% of cases and its position had to be adjusted using fluoroscopy to ensure correct intra-articular placement. The investigators conclude that it is difficult to reliably enter the TMC joint space with a blind pass of the needle, and that image intensification greatly facilitates correct needle placement.1 In another investigation, nonguided injection was performed by an experienced hand surgeon using anatomic landmarks. In this investigation, 32 patients with symptomatic carpometacarpal osteoarthritis underwent nonguided injection using anatomic landmarks, which were not defined, to guide needle placement in an office setting with hylan GF-20 (Synvisc) as part of an open label trial. After injection, the patient was immediately taken to an adjacent ultrasound suite, where the injected joint was examined under ultrasound for evidence of intra-articular material and air microbubbles. Results showed that all patients had ultrasound evidence of intra-articular material. The investigators concluded that carpometacarpal injections can be performed accurately in the office, without the need for radiologic guidance in patients with moderate to severe carpometacarpal osteoarthritis.6 A more recent study evaluated the accuracy of intra-articular injection of the basal joint of the thumb and determined the rate of soft-tissue extravasation. The basal joints of 30 cadaver hands were injected using a 25-gauge 1.5-in needle and radiopaque dye. Eight of the 30 cadaver specimens were injected with fluoroscopy-guided needle placement in an attempt to duplicate ideal conditions and create an intra-articular criterion standard for comparison purposes. The remaining 22 hand specimens were injected without fluoroscopy-guided needle placement. The investigators reported that the rate of intra-articular needle placement was 100% for the fluoroscopy-guided group and 81.8% for the nonguided group. Although not statistically significant (P=.546), the investigators reported that the accuracy rates of intra-articular injection into the thumb basal joint compare favorably with reported rates of knee injection accuracy, which range from 71% to 100%.7 Thus, the variability in the literature suggests that operator experience and the use of image guidance may impact success.
Although the pain associated with intra-articular joint injection has yet to be studied using ultrasound-guidance, a recent prospective study evaluated the tolerability of hyaluronic acid viscosupplementation in patients with trapeziometacarpal osteoarthritis and compared the pain of injections given with and without fluoroscopy control. Sixteen patients with Eaton stages 3 or 4 osteoarthritic changes at the trapeziometacarpal joint were recruited for this study. Using an insulin syringe needle, 8 patients underwent 1 injection of sodium hyaluronate per week for 3 weeks using fluoroscopic guidance, and 8 patients had the same injection performed nonguided. Pain associated with the injection was measured using the 10-mm visual analog scale (VAS). Patients were also asked to evaluate treatment tolerability from poor to excellent (using a 0 to 4 scale). Results from this investigation revealed a VAS score of 4.1 in the group who underwent fluoroscopically guided injection, compared with the nonguided group, who had a VAS score of 5.6, which was statistically significant (P<.005). Most patients had a moderate to good tolerance of the injection. During the investigators’ clinical applications, they observed that the intra-articular injection into the carpometacarpal joint is a painful procedure, especially if it is done without fluoroscopy control, perhaps due to periarticular injection or periosteal irritation when performed nonguided.10 Future research in this area may show that the use of other imaging modalities, such as ultrasound, may provide equal pain tolerability without the potentially harmful radiation exposure.
To our knowledge, no formal studies exist that describe a technique to perform an ultrasound-guided injection of the TMC joint using steroid preparations, and verify its accuracy using contrast fluoroscopy as a criterion standard. TMC joint arthritis is common and there are limited treatment options, with steroid injection being commonly used for symptomatic treatment. Prior literature indicates significant variability in the technical success of TMC joint injections. Although the specific reasons for this remain indeterminate, factors such as operator experience and distorted anatomy have been proposed to explain the challenge of accurate injectate placement into the TMC joint. Preliminary work in our practice shows promising results using ultrasound to guide accurate needle placement for the delivery of steroid preparations, especially in extensive arthritic TMC joints.
Study Limitations
Shortcomings of this study include the use of a relatively small sample size, the use of fresh frozen hand specimens, performing this procedure under nonsterile conditions, and failing to adjust the ultrasounds’ field of view, thus making identification of a specific joint more difficult. Although our results are encouraging for using ultrasound to guide intra-articular TMC joint injection, further studies involving a randomized, double-blind patient population are needed to examine the accuracy and efficacy of ultrasound compared with fluoroscopic-guided injection into arthritic TMC joints. This may help to better define the role of ultrasound in clinical practice.
Conclusions
Nonguided TMC joint injections can be challenging. This report describes a technique for performing an ultrasound-guided injection of the TMC joint and verifies accurate needle placement using a cadaveric model. It is anticipated that the use of ultrasound to guide injection into the TMC joint may prove to be a safe and viable alternative to fluoroscopy in the appropriate clinical setting. This may be especially pertinent when image guidance is needed for diagnostic precision and therapeutic management in patients with severe arthritic TMC joints and those who have failed nonguided injection.
Suppliers
References
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- . A randomized controlled trial of intra-articular corticosteroid injection of the carpometacarpal joint of the thumb in osteoarthritis. Ann Rheum Dis. 2004;63:1260–1263
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No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated.
PII: S0003-9993(07)01595-X
doi:10.1016/j.apmr.2007.07.048
© 2008 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
Volume 89, Issue 1 , Pages 153-156, January 2008
